CONTINUING EDUCATION
Course Number: 195
The Single-Stage Implant Procedure:
Science or Convenience?
Dale R. Rosenbach, DMD, MS
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CONTINUING EDUCATION
Thirty years later, some would argue that due to both our more
advanced understanding of osseointegration and our remarkably
overwhelming emphasis on soft-tissue aesthetics of the final
restoration, we witness the placement of healing abutments
often at the same time as implant placement in what is termed
a single-stage procedure—this can also be referred to as immediate
abutment placement (IAP). But others might counter that healing
abutments are placed with increasing frequency at the time of
implant placement simply because it’s more convenient.
The paucity of formal investigation on the relative risks
and benefits between IAP and DAP unfortunately precludes a
rigorous evaluation of evidence-based best practice. Instead,
this article presents an informal review of the risks and benefits
of the 2 procedures as currently understood. Support will be
drawn from the literature, when available, as well as from
clinical experience, opinion, and consensus, in the hopes that
this review might guide clinical practice until such time as a
preponderance of well-controlled data can direct clinicians in a
more authoritative fashion.
The Single-Stage
Implant Procedure:
Science or Convenience?
Effective Date: 03/01/2016 Expiration Date: 03/01/2019
Learning Objectives: After reading this article, the individual will learn:
(1) if there is a strong clinical rationale for immediate implant abutment
placement (IAP), and (2) the risks and benefits of delayed implant abutment
placement versus IAP.
About the Author
Dr. Rosenbach received his undergraduate
degree in biology from Yeshiva University and
his dental degree from New Jersey Dental
School. After completing a one-year general
practice residency (GPR) at Woodhull Medical
Center (Brooklyn, NY), he worked in private
practice for a year, then he attended Columbia University for his postdoctoral training
in perio­dontics and implant dentistry, completing a master’s degree focusing on the
effects of abutment dis/reconnection on initial peri-implant bone loss. He is a Diplomate
of the American Board of Perio­dontology, and
is currently the associate director of the PGY2/3 implant fellowship and course director of
the periodontics and implant dentistry lecture series in the GPR at Woodhull
Medical Center. He serves as the head of project for WikiProject Dentistry on
Wikipedia, and is an internationally recognized lecturer, presenting more than
400 hours of continuing education on topics related to periodontics, implant
dentistry, and adjunctive surgical procedures. He maintains a practice limited
to periodontics and surgical implantology in New York City. He can be reached
at [email protected].
THE ROLE OF THE HEALING ABUTMENT
Early descriptions in the literature involving the role of the
healing abutment are difficult to locate. Some texts refer to
Stage II (initial fixture uncovering after healing) by discussing
the placement of a final abutment. It is only if the clinician has
difficulty in determining the final apicocoronal height of the
gingival collar to which to match an appropriately sized final
abutment collar height that it is recommended to instead opt for
a healing abutment.2 The benefit provided by this intermediate
step is that a healing abutment possesses an undefined collar
Disclosure: Dr. Rosenbach has received honoraria for lecturing from Implant Direct.
H
istorically, a dental implant was placed into an edentulous site, at which time a cover screw was affixed. The
implant platform was ideally countersunk to a depth of
about one to 2 mm subcrestally so as to be “fully embedded”—
thus, even after placement of the cover screw, the soft-tissue flap
could be replaced over the surgical site and be able to “rest on
the jaw between fixtures and not directly on the cover screws.”1
According to original Brånemark protocols and depending on
the site, after waiting anywhere from 4 to 6 months for osseointegration, an abutment was placed during a second-stage surgical
entry as part of what is termed a 2-stage procedure—this can also
be referred to as delayed abutment placement (DAP).
Figure 1. Contrasting use of a final abutment and a healing abutment at
Stage II. If a final abutment is used at Stage II, the formation of the gingival margin may be at the restorative margin (A), coronal to it (B), or apical
to it (not shown). Conversely, because there is no finish line on a healing
abutment, it does not matter if the gingival margin forms more apically (C)
or more coronally (D), and an appropriate final abutment may be chosen to
match the level of the gingival margin that formed on the healing abutment.
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CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
height—in a sense, its entire height is collar height due to the
absence of a finish line (Figure 1). The soft tissue is permitted to
heal against the healing abutment and define its own dimensions,
which can then be measured and matched to a corresponding
stock or custom final abutment.
Throughout time, a number of objectives have been
developed for the second-stage surgery. It is important to note,
however, that they are really objectives of abutment placement,
notwithstanding the timing of this placement, and it is only
because DAP was universally employed in all cases that the
2 became synonymous. Now that IAP is a clinical reality, it is
essential to conceptualize the 2—placement of the healing
abutment and second-stage surgery—as distinct entities.
In order to recognize IAP as an acceptable alternative to DAP, it
must be established that IAP can be reasonably expected to meet
or exceed the stated goals of DAP (and in reality, of abutment
placement as a whole) without contributing unnecessary
compromise from surgical, restorative, functional, and aesthetic
perspectives.
This article will begin by examining the stated objectives
of second-stage surgery, assessing whether IAP achieves the
same goals, with recommendations made to best achieve each
objective. After discussing some other considerations related to
IAP versus DAP, reasonable therapeutic recommendations will
be advanced for the best timing of abutment placement.
Table. Objectives at Second-Stage Surgery3,4
1. T o expose the submerged implant without damaging the
surrounding bone
2. T o control the thickness of the soft tissue surrounding
the implant
3. T o preserve or create attached keratinized tissue around
the implant
4. To ensure proper abutment seating
5. To develop appropriate soft-tissue contours
regarded as clinically insignificant in some cases, in others it
may not be. More investigation is necessary to reach a conclusive
assessment.
When apically positioning the soft tissue in order to
preserve or positively augment the zone of keratinized tissue
(in fulfillment of objective 3), one can employ a split-thickness
flap to maintain vascularization to the superficial aspect of
the ridge, thus diminishing the effect that raising a flap might
cause.6 However, some investigations found that split-thickness
flaps contributed to more superficial bone loss7,8 and greater
risk of flap necrosis due to an increased disturbance to the flap
vasculature and delayed re-anastomosis of flap vessels.9
Conclusion: Peri-implant bone preservation associated with
IAP appears to be at least as good as, if not superior to, that
associated with DAP.
THE OBJECTIVES OF SECOND-STAGE SURGERY
The objectives of DAP at second-stage surgery are listed in the
Table.3,4
Objective 2: Controlling Soft-Tissue Thickness
Minimizing an excessive thickness of tissue at the time of implant
placement avoids the need for raising a more considerable flap at
the time of DAP (see objective 1). Repeated tissue manipulation
during oral surgical procedures has been shown to result in
compromise to both osseous crest5,10 and gingival11,12 levels,
although some have countered that high plaque levels and
short follow-up duration, respectively, can be blamed for the
unfavorable research data.13
If the intention is to thicken the peri-implant soft tissue, such
as by adding a connective tissue graft14 or by employing a palatal
roll technique,15 such a procedure can be done simultaneously
with IAP, although results may be better if the tissue is augmented
without the presence of a transmucosal metal component.
Soft-tissue thickness is of critical concern at the buried implant
site. If the soft tissue is too thin over a submerged implant and
a communication forms during healing so that the cover screw
becomes exposed at the level of the gingival margin, biologic
width will form on the coronal extent of the circumference of the
fixture,16 resulting in initial peri-implant bone loss (Figure 2).17
Objective 1: Avoiding Damage to Peri-Implant Bone
While exposing an implant to switch the cover screw for a healing
abutment during DAP, it is difficult to surgically lift only the soft
tissue resting precisely atop the cover screw, and so very often,
a small amount of soft tissue is reflected from the surrounding
bone as well. Even when accessing the cover screw with a tissue
punch, it is common to use a punch diameter slightly larger
than the platform diameter so as to avoid the presence of softtissue shreds that may prevent complete seating of the healing
abutment (in fulfillment of objective 4).
It has been demonstrated that raising a flap from the osseous
crest results in bone loss even in the absence of active bone
removal by the clinician because of the resultant compromise
to the osseous blood supply.5-7 Removing the soft tissue from the
area immediately surrounding the circumference of the implant
platform may thus compromise the crestal bone, contributing
to a magnitude of initial peri-implant bone loss. While such a
minute amount of peri-implant soft-tissue reflection may be
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CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
a
b
c
Figure 2. Gingival fenestration due to excessively thin occlusal soft tissue.
Early inadvertent exposure of an implant as viewed from the (a) occlusal
and (b) facial perspectives. Because transgingival exposure necessitates
the formation of biologic width, and a cover screw does not possess enough
apicocoronal height for biologic width to form onto it alone, biologic width
forms on the implant fixture itself, leading to (c) initial peri-implant bone
loss.
a
b
c
d
Figure 3. Apically positioned flap during delayed abutment placement (DAP)
for multiple adjacent fixtures. (a) Cover screws for implant Nos. 2, 3, and
5 are visible through the thin soft tissue, and the mucogingival junction
passes over the occlusal aspect of the ridge. (b) To maintain a wide zone
of keratinized tissue, an apically positioned flap was performed during DAP.
(c) To minimize peri-implant bone loss following flap reflection, a less
invasive split-thickness flap was employed. (d) The flap was then sutured
securely into place against the buccal aspects of the healing abutments.
To summarize, IAP has the potential for similar or better
results when the tissue is either sufficiently thick or abundantly
thick and there is an intention to thin it out. When the tissue in
the area surrounding and overlying the occlusal aspect of the
fixture is very thin, soft-tissue grafting may be performed at the
site prior to implant placement, at the same time as implant
placement following the placement of a cover screw, or against
a healing abutment during IAP. Greater success has been
observed when the graft is placed against denuded bone18 or
split-thickness connective tissue19 and sandwiched under flap
tissue than if allowed to both remain somewhat exposed and
if placed mostly against the avascular surface of exposed roots
for the purposes of root coverage when maximal blood supply
was not afforded to the graft,20 and this may be extrapolated
to the avascular surface of metal transmucosal components.
Following grafting, soft-tissue stability may not be achieved
at the peri-implant site for up to 3 to 6 months,21 especially in
the maxillary anterior where soft tissue may tend to be thinner and where aesthetic demands may be higher.22 For this reason, when gingival margins are deemed very thin on the flaps
formed during surgical access for implant placement, connective tissue grafting may be recommended along with DAP, as
opposed to attempting to graft against an abutment during IAP.
Conclusion: Soft-tissue thickness around an implant can be
reduced with IAP in a similar fashion as it can be with DAP.
Thickening soft tissue via soft-tissue grafting can also be done
simultaneously with IAP, or can be attempted during Stage I
while performing DAP.
While some have argued that research on peri-implant
keratinized tissue is irrelevant either due to statistical skewing or nongeneralizable data from implant surfaces no longer
used, the fact is that keratinized tissue demonstrates either
equivalent or superior results when it comes to indices such as
plaque accumulation, inflammation, probing depths, and loss
of either bone or clinical attachment.26,28 As such, if one can
easily preserve, or create in its absence, a zone of keratinized
tissue, it might be prudent to do so (Figure 3).29 If a deficiency
of keratinized tissue is evident during the treatment planning
phase of implants, some researchers have reasonably proposed
augmenting the tissue either prior to implant placement30 or
simultaneous with implant placement,31 followed by DAP.
The literature discusses imaginative proposals as to how one
might develop keratinized tissue around healing abutments,32
although they are technique sensitive and some have been published as retrospective case reports. Other approaches that are
much less technique sensitive and have demonstrated compellingly successful increases of keratinized tissue at tooth sites
may be employed around healing abutments (or final abutments with crowns) with greater ease,33-35 but they are largely
intended for midfacial augmentation. Papillae reconstruction
techniques have also been developed,36 but they are far from
ideal; their own investigators lament the difficulties involved
in splitting mini-flaps and employing these techniques in the
presence of thin facial soft tissue, and the majority of cases
demonstrated partial papillae fill.37
Conclusion: In a situation where keratinized tissue is lacking,
DAP may be more appropriate, unless grafting procedures can
be implemented simultaneously with IAP.
Objective 3: Preserving or Creating
a Sufficient Zone of Keratinized Tissue
While the preponderance of evidence has still not demonstrated the essentiality of a sufficient zone of keratinized tissue
to prevent inflammation, attachment loss, or recession around
teeth23-25 or implants,26 some would argue that this is a pressing issue to consider when it comes to implants.27
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The Single-Stage Implant Procedure: Science or Convenience?
Objective 4: Ensuring Proper Abutment Seating
One can encounter varying degrees of difficulty when attempting to seat a component on an implant platform, including cover
screws and also healing abutments during both IAP and DAP. A
cover screw is virtually always either the same diameter as the
implant platform (termed platform matching) or of a smaller diameter (termed platform switching), and so is quite simple to place once
the male thread pattern of the screw catches in the female thread
pattern of the internal well of the implant fixture. However, if an
implant platform is placed even partially subcrestal, a platform
matched cover screw may catch on the coronal edge of bone. This
can also occur with platform matched healing abutments, during
both IAP and DAP, and it is important to confirm seating upon all
subcrestal platforms with appropriately angled radiographs (generally, bite-wings provide the greatest diagnostic accuracy to confirm component seating).38 Even though the components match
the diameter of the fixture, the latter might not have been held up
by the edge of bone as a result of the greater torque applied to seat
it completely into the depth of the osteotomy.
Healing abutments may be flared in what is often termed
an anatomic profile, and if this flare begins apically enough, the
healing abutment may catch on the edge of the osteotomy and
not seat fully. This can also be an issue in the case of IAP on an
immediate implant for which the flare of the healing abutment
is greater than the flare of the walls of the extraction socket. In
such a case, the bone may be reduced or a straight profile healing
abutment may be appropriate (Figure 4).39
Because of the tendency of anatomic profile healing abutments
to catch on bone that extends coronally past the implant platform,
one may encounter enormous difficulties when attempting to
perform DAP through a punch access to the bone during Stage
II. This is because coronal irregularities of the crest relative to
the implant platform may not be obvious without visual access
in the absence of a soft-tissue flap, and radiographic examination
of the area may not pick up on minute prematurities of contact
between the flare of the healing abutment and the osseous
crest, especially if they are on the facial or lingual/palatal and
thus superimposed on the abutment as seen on the radiograph.
Even though such prematurities may also exist during IAP, good
access and visualization of the surgical site are usually available,
except in the instance of a flapless implant placement (Figure 5).
Conclusion: Full surgical and visual access to the implant
platform is ideal when placing healing abutments. IAP affords
this opportunity without additional compromise to the periimplant bone (see objective 1).
a
b
c
d
Figure 4. Use of an anatomic abutment when fixture is placed partially
subcrestal. Because of the occlusal curvature of the alveolar ridge in
the bucco-lingual dimension, (a) the platform becomes about 1.0 mm
subcrestal interproximally when placed at the crest midfacially, as can be
seen by the partially subcrestal fixture mount and (b) the exposed platform.
(c) Initially, the anatomic healing abutment became caught up on the periimplant crestal bone on the mesial and would not fully seat. (d) Following
adjustment of the crestal bone with hand instruments, the flared anatomic
abutment was able to be seated appropriately.
a
b
Figure 5. Anatomic versus straight healing abutment. Fixture No. 31 was
placed in a ridge with a bucco-lingual dimension narrow enough that for the
platform to be flush with the bone mid-facially, the interproximal had to be
about 1.0 mm subcrestal. This configuration made it (a) impossible to seat
the anatomic healing abutment, and so (b) a straight abutment was placed
instead.
have a favorable influence on the development of soft-tissue
contours around implants. And, as stated above, decreasing
the number of surgical re-entries has been shown to provide
exceptional benefits in terms of both soft- and hard-tissue
preservation (Figure 6).40
When these objectives were first conceived and delineated,
immediate implant dentistry (implants being placed at the
time of tooth extraction) was either nonexistent or still in
its infancy, and so the discussion revolved around developing
appropriate soft-tissue contours as opposed to maintaining these
contours. With the benefits of minimally invasive surgical
Objective 5: Developing Appropriate Soft-Tissue Contours
Maintaining the greatest volume of bone and of soft tissue can
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CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
Figure 6. Soft-tissue access for implant placement and developing soft-tissue
extraction being understood as
contours by employing immediate abutment placement (IAP). Anticipating IAP
worth the general inconvenience
with placement of this fixture into edentulous site No. 3, the alveolar ridge was
of increased surgical time and
accessed with a double-papillae sparing H incision that placed the mid­crestal
incision in an ideal location to accept the healing abutment. An anatomic healing
more specialized extraction techabutment is used here to develop a better soft-tissue emergence profile. The
41-43
niques,
the gingival margin
mean dimensions of a maxillary first molar at the cemento-enamel junction are
at an immediate implant site
7.9 mm mesiodistally and 10.7 mm buccopalatally,* but the implant used is
only 5 mm in diameter. This abutment brings the soft tissue to 6.5 mm in diamecan often be left virtually undister, more closely resembling that of the natural tooth. (*Woelfel’s Dental Anatomy,
turbed. Numerous investigators
published data from investigation spanning 1974 to 1979.)
firmly underscore the importance of maintaining the existing
soft-tissue contours via placement of either a custom healing
OTHER CONSIDERATIONS
abutment or full-crown provisionalization.4,44-46 Some agree
Time Management
that while preserving the coronal contours near the gingival The most obvious and objective gain of IAP is avoiding the need for
margin is ideal, emphasis should be placed on developing an a second surgery. The benefit of simplified patient management
increased apical thickness of soft tissue by platform switching should not be understated. It is not a secret that some patients fear
with highly flared abutments47or introducing apical concav- the dentist in general, and perhaps the underlying issue can be
ities onto abutments48 for the benefit of both hard- and soft- tied to a more specific fear of administration of local anesthesia
tissue preservation.49
and surgical intervention, no matter how seemingly insignificant.
Other researchers stress the importance of having the emer- Furthermore, distinct financial reimbursement for DAP is often
gence profile develop as gradually, and thus as apically, as possi- nonexistent; therefore subsuming the abutment placement
ble44,50,51 because it is necessary to compensate for the fact that procedure into the same visit as the implant placement procedure
implant platforms generally exhibit a smaller diameter than is both time and cost efficient. The fewer the number of procedures,
the cross-section cervical shape of the crown being supported the more superior the care, assuming no significant compromises
by the implant.52 Because of this, they assert that a substan- are introduced as a result.55
tial enough transition between the 2 must occur if aesthetics
and cleansability are duly considered. Still others recommend
Risk of Occlusal Loading
undercontouring the healing abutment to initially produce a Occlusal loading may be the greatest concern related to IAP.
greater volume of peri-implant soft tissue. A gentle yet signifi- Initially, it was thought that it was necessary to allow implant
cant overcontour of the final abutment can then be introduced fixtures time to integrate prior to exposing them to the oral
to push the increased volume of soft tissue for more superior cavity with transmucosal attachments.1,4,56 Current information
aesthetic results—with this technique, the midfacial gingival shows that this is not the case.
margin can be displaced coronally and the interproximal tissue
If IAP is performed, some worry that forces applied to the
can be displaced to achieve a more complete papilla fill.53 How- exposed abutment during healing can result in failure to
ever, this technique can be considered very technique sensitive, integrate successfully. In contrast to this, a remarkable volume
as even the authors53 admit that even a slightly greater overcon- of literature has been published endorsing IAP on the grounds
tour than the gingiva can handle can result in an apical shift of that it carries many potential benefits (as discussed above) while
the gingival margin. More investigation is required.
not contributing to diminished survival.57-62 The literature even
Still others show a lack of statistically significant benefit demonstrates that when ample primary stability is achieved,
of flared abutments over straight abutments in terms of immediate loading can be a predictably successful option.63-66
soft-tissue development, although effects on the bone were
In contrast, if an implant does not possess sufficient primary
admittedly not evaluated.54 A balance between the different stability, early force application via an exposed healing fixture
perspectives is one that requires greater investigation to may interfere with osseointegration.
substantiate clinical rationale.
Conclusion: IAP, and perhaps specifically with customized
Bone Grafting at the Time of Implant Placement
or specially designed abutments at immediate extraction sites, Introducing bone graft material at an implant site during initial
appears to favor preservation of the immediate socket soft-tissue placement may make it more difficult to perform IAP (Figure 7).
profile more than DAP, so the final implant restoration may best In such a case, DAP may be advantageous because of how the
mimic the tooth it is meant to replace.
presence of a healing abutment may interfere with such things
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CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
as planning the incision design, use of membranes, flap advancement procedures, desire for primary closure, ease of suturing,
and flap securement.3
For more conservative peri-implant grafting, such as when an
osteotomy was shifted during enlargement or in the gap around
an implant placed immediately into an extraction socket, there
may not be as much need for concern. If immediate implants are
placed into sockets at which no flaps were raised, management
of the surgical site becomes far simpler. If peri-implant gaps are
large enough to manage and graft material is introduced around
the secured fixture, bone may either be left exposed or graft containment techniques utilizing collagen tape may be employed
that either lie over the healing abutment or through which the
healing abutment perforates with no decrease in success.67,68
Alternatively, a custom healing abutment may be used to contain the graft material and effectively seal in the blood clot.44
a
b
Figure 7. Grafting around an implant at the time of placement. These 2
fixtures (Nos. 13 and 15) were placed 4 months following extraction and
socket preservation with an alloplast material that failed to integrate. After
debriding the sockets of the residual graft matter and placement of implants
into ideal position for future restoration, peri-implant gaps are evident: (a)
occlusal view and (b) facial view. Primary stability for No. 13 registered at
around 10 Ncm and for No. 15 around 40 Ncm. Because of the low stability
at the premolar site and the grafting that will be done concurrent with fixture
placement, it was decided to employ DAP and cover screws were placed.
CONCLUSION
Clinical Recommendations
IAP appears to be equivalent to DAP in all objectives except
when there is either a deficiency in primary stability, or softtissue thickness or keratinization. Notwithstanding, some
investigators have developed methods of soft-tissue augmentation that have been shown to be predictable even when done
at the same time as placement of a healing abutment.
Based on the available data and the clinical experience of those
who have been performing IAP with regularity for a considerable amount of time, the following factors ought to be taken into
account when considering the timing of abutment placement:
1. IAP has been shown to meet or exceed the demands of healing abutment placement in many situations.
2. IAP reduces both chair time and the number of surgical procedures. IAP also reduces the number of times a patient needs to be
anesthetized, a procedure that most patients would prefer to avoid.
3. When sufficient primary stability has been achieved, the
concern of early overloading may be overemphasized. At this
time, however, the characteristics of sufficiency of stability (ie,
degree of stability and extent of fixture surface area engaging
bone) have not been well defined. Two currently utilized parameters of stability, final surgical torque value and implant stability quotient, are only modestly informative, as they do not take
primary stability into account as a function of the surface area,
which may be a critical component that is overlooked. Further
study is required in this area.
4. Healing abutments should not extend more than 2 mm
coronally from the gingival margin to limit force transmission
during mastication. It should be out of occlusion in all excursions and protrusive. Care should be taken in patients with a
history of parafunctional habits, and clinicians should confirm
that healing abutments exhibit clearance not only from opposing teeth, but also from any removable appliances or devices,
such as athletic guards or nightguards.
5. If there is no intention to augment the zone of keratinized tissue, healing abutments should be placed at the time of
implant placement to avoid unnecessary surgical re-entry. Even
if keratinized tissue is deemed deficient, techniques do exist for
augmenting soft tissue following fixation of transmucosal components, although the clinician should either be familiar with
these types of procedures or consult with another who is.F
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16.Berglundh T, Lindhe J. Dimension of the peri-implant mucosa. Biological width revisited. J Clin Periodontol. 1996;23:971-973.
17.Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier at implants and teeth.
Clin Oral Implants Res. 1991;2:81-90.
18.Wilcko MT, Wilcko WM, Murphy KG, et al. Full-thickness flap/subepithelial connective
tissue grafting with intramarrow penetrations: three case reports of lingual root coverage. Int J Periodontics Restorative Dent. 2005;25:561-569.
19.Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Perio­
dontics Restorative Dent. 1994;14:126-137.
20.Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage.
I. Rationale and technique. Int J Periodontics Restorative Dent. 1994;14:216-227.
21.Small PN, Tarnow DP. Gingival recession around implants: a 1-year longitudinal prospective study. Int J Oral Maxillofac Implants. 2000;15:527-532.
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23.Wennström JL. Mucogingival therapy. Ann Periodontol. 1996;1:671-701.
24.Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival
grafts. J Clin Periodontol. 1980;7:316-324.
25.Wennström JL. Lack of association between width of attached gingiva and development of soft tissue recession. A 5-year longitudinal study. J Clin Periodontol.
1987;14:181-184.
26.Greenstein G, Cavallaro J. The clinical significance of keratinized gingiva around dental
implants. Compend Contin Educ Dent. 2011;32:24-31.
27.Abrahamsson I, Berglundh T, Wennström J, et al. The peri-implant hard and soft tissues
at different implant systems: a comparative study in the dog. Clin Oral Implants Res.
1996;7:212-219.
28.Chung DM, Oh TJ, Shotwell JL, et al. Significance of keratinized mucosa in maintenance of dental implants with different surfaces. J Periodontol. 2006;77:1410-1420.
29.Yeung SC. Biological basis for soft tissue management in implant dentistry. Aust Dent
J. 2008;53(suppl 1):S39-S42.
30.Barone R, Clauser C, Grassi R, et al. A protocol for maintaining or increasing the width
of masticatory mucosa around submerged implants: a 1-year prospective study on 53
patients. Int J Periodontics Restorative Dent. 1998;18:377-387.
31.Covani U, Marconcini S, Galassini G, et al. Connective tissue graft used as a biologic
barrier to cover an immediate implant. J Periodontol. 2007;78:1644-1649.
32.Adriaenssens P, Hermans M, Ingber A, et al. Palatal sliding strip flap: soft tissue management to restore maxillary anterior esthetics at stage 2 surgery: a clinical report.
Int J Oral Maxillofac Implants. 1999;14:30-36.
33.Carnio J, Camargo PM. The modified apically repositioned flap to increase the dimensions of attached gingiva: the single incision technique for multiple adjacent teeth. Int
J Periodontics Restorative Dent. 2006;26:265-269.
34.Harris RJ. Clinical evaluation of 3 techniques to augment keratinized tissue without
root coverage. J Periodontol. 2001;72:932-938.
35.Yan JJ, Tsai AY, Wong MY, et al. Comparison of acellular dermal graft and palatal
autograft in the reconstruction of keratinized gingiva around dental implants: a case
report. Int J Periodontics Restorative Dent. 2006;26:287-292.
36.Tinti C, Benfenati SP. The ramp mattress suture: a new suturing technique combined
with a surgical procedure to obtain papillae between implants in the buccal area. Int
J Periodontics Restorative Dent. 2002;22:63-69.
37.Nemcovsky CE, Moses O, Artzi Z. Interproximal papillae reconstruction in maxillary
implants. J Periodontol. 2000;71:308-314.
38.Greenstein G, Cavallaro JS Jr, Tarnow DP. Clinical pearls for surgical implant dentistry:
Part 1. Dent Today. 2010;29:124-127.
39.Greenstein G, Cavallaro JS Jr, Tarnow DP. Clinical pearls for surgical implant dentistry:
Part 2. Dent Today. 2010;29:64-68.
40.Cardaropoli G, Lekholm U, Wennström JL. Tissue alterations at implant-supported
single-tooth replacements: a 1-year prospective clinical study. Clin Oral Implants Res.
2006;17:165-171.
41.Cavallaro JS Jr, Greenstein G, Tarnow DP. Clinical pearls for surgical implant dentistry:
Part 3. Dent Today. 2010;29:134-139.
42.Cavallaro JS Jr, Greenstein G. Immediate dental implant placement: technique, part
2. Dent Today. 2014;33:94-98.
43.
Rosenbach DR. How to extract teeth as atraumatically as possible. Dental
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how-extract-teeth-atraumatically-possible-0. Accessed December 21, 2015.
44.Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic concept of managing
immediate implant placement and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent. 2012;33:524-534.
45.Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization
of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac
Implants. 2003;18:31-39.
46.Trimpou G, Weigl P, Krebs M, et al. Rationale for esthetic tissue preservation of a fresh
extraction socket by an implant treatment concept simulating a tooth replantation.
Dent Traumatol. 2010;26:105-111.
47.Puisys A, Linkevicius T. The influence of mucosal tissue thickening on crestal bone
stability around bone-level implants. A prospective controlled clinical trial. Clin Oral
Implants Res. 2015;26:123-129.
48.Rompen E, Raepsaet N, Domken O, et al. Soft tissue stability at the facial aspect of
gingivally converging abutments in the esthetic zone: a pilot clinical study. J Prosthet
Dent. 2007;97(suppl 6):S119-S125.
49.Linkevicius T, Apse P, Grybauskas S, et al. The influence of soft tissue thickness on
crestal bone changes around implants: a 1-year prospective controlled clinical trial.
Int J Oral Maxillofac Implants. 2009;24:712-719.
50.Kois JC. Predictable single tooth peri-implant esthetics: five diagnostic keys. Compend
Contin Educ Dent. 2001;22:199-206.
51.Rojas-Vizcaya F. Biological aspects as a rule for single implant placement. The 3A-2B
rule: a clinical report. J Prosthodont. 2013;22:575-580.
52.Cavallaro JS Jr, Greenstein G. Prosthodontic complications related to non-optimal
dental implant placement. In: Froum SJ, ed. Dental Implant Complications: Etiology,
Prevention, and Treatment. Oxford, England: Wiley-Blackwell; 2010:156-171.
53.Su H, Gonzalez-Martin O, Weisgold A, et al. Considerations of implant abutment and
crown contour: critical contour and subcritical contour. Int J Periodontics Restorative
Dent. 2010;30:335-343.
54.Patil RC, den Hartog L, van Heereveld C, et al. Comparison of two different abutment
designs on marginal bone loss and soft tissue development. Int J Oral Maxillofac
Implants. 2014;29:675-681.
55.Buser D, Wittneben J, Bornstein MM, et al. Stability of contour augmentation and
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results of a prospective study with early implant placement postextraction. J Periodontol. 2011;82:342-349.
56.Block MS. Anesthesia, incision design, surgical principles and exposure techniques.
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57.De Rouck T, Collys K, Wyn I, et al. Instant provisionalization of immediate single-tooth
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2009;20:566-570.
58.Block MS, Mercante DE, Lirette D, et al. Prospective evaluation of immediate and
delayed provisional single tooth restorations. J Oral Maxillofac Surg. 2009;67(suppl
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59.Cooper LF, Raes F, Reside GJ, et al. Comparison of radiographic and clinical outcomes following immediate provisionalization of single-tooth dental implants placed
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2010;25:1222-1232.
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immediate implants: clinical outcomes and esthetic results. Clin Oral Implants Res.
2007;18:552-562.
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2009;20:1307-1313.
62.Hämmerle CH, Lang NP. Single stage surgery combining transmucosal implant placement with guided bone regeneration and bioresorbable materials. Clin Oral Implants
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67.Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immediate
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Clin Oral Implants Res. 2004;15:285-292.
7
CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
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POST EXAMINATION QUESTIONS
1. All of the following are true about the second-stage
implant procedure except:
a. It was initially touted as absolutely necessary for successful
integration to occur.
b. It can better prevent forces from transmitting to the healing
fixture.
c. It is synonymous with an immediate abutment placement (IAP)
protocol.
d. It refers to the placement of a cover screw at the time of
implant placement.
3. All of the following are listed as objectives of second-stage
surgery in the article except for:
a. P
reserving or creating attached keratinized tissue around the
implant.
b. E
xposing the submerged implant without damaging the
surrounding bone.
c. E
nsuring that gingival fibers in the soft tissue run parallel to the
surface of the healing abutment.
d. Developing appropriate soft-tissue contours.
4. A
healing abutment is virtually always wider than the
implant platform it sits upon so as to:
a. Prevent bone growth over the top of the platform.
b. Retard apical migration of the junctional epithelium.
c. Prevent apical transmission of lateral forces.
d. None of the above.
2. Historically, use of a healing abutment before a final
abutment was seen as a benefit because:
a. Healing abutments are made of aluminum, which prevents an
oxide layer from forming at the implant-abutment junction.
b. Placing healing abutments is easier, faster, and less expensive
because they had always been included with the implant.
c. While final abutments generally engage the anti-rotational
device of the implant fixture, healing abutments spin freely until
they are flush with the platform.
d. Instead of trying to get the soft tissue to conform to the finish
line of the final abutment, a healing abutment permits the
soft-tissue margin to form at will, and the final abutment can
then be made to correlate with this level.
5. W
hich radiographic modality provides the greatest
diagnostic accuracy when attempting to confirm
component seating on an implant platform?
a. The bite-wing radiograph.
b. The periapical radiograph.
c. The Reverse Towne’s projection.
d. The panoramic radiograph.
8
CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
6. P
rematurities of the crestal bone may interfere with proper
seating during abutment placement. When flap access is
performed for implant placement, IAP permits the clinician
to have good surgical access and visualization for this
procedure.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.
8. A
ccording to the article, attempting hard-tissue grafting
at the same time as implant placement may interfere with
IAP in all of the following ways except:
a. A
dvancing, securing, and achieving primary closure of the
gingival flap.
b. Incorporating the use of a barrier membrane.
c. Achieving adequate primary stability of the fixture.
d. Simplicity of suturing technique.
9. An immediate implant may be placed into porous bone. If
immediately provisionalizing such an implant, it is important
to ensure that occlusal contact cannot be made in
protrusive, but checking lateral excursions is not important.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.
7. A
ccording to the article, why do some researchers
emphasize how important it is to begin the restorative
emergence profile as apically as possible?
a. If the emergence profile begins too coronally, there won’t be
adequate embrasure space for the papilla.
b. For the most favorable crown-to-implant ratio, the emergence
profile should begin as close to the implant-abutment junction
as possible.
c. For best functional and aesthetic success, it’s best to have a
more gradual expansion of the small diameter of the implant
platform to the generally larger cross-section cervical shape of
the crown.
d. Without an apically situated emergence profile, excessive
stress can be transmitted to the abutment screw, leading to
more frequent screw loosening.
10. A
n IAP protocol may be performed with a customized
temporary abutment. An IAP protocol is relevant only in
the so-called “aesthetic zone.”
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.
9
CONTINUING EDUCATION
The Single-Stage Implant Procedure: Science or Convenience?
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